Department of Cardiothoracic Surgery, University Hospital Vienna, Vienna, Austria.
J Thorac Cardiovasc Surg. 2013 Jan;145(1):159-65. doi: 10.1016/j.jtcvs.2011.10.093. Epub 2012 Feb 11.
To assess the efficacy and midterm results of endovascular treatment of acute complicated type B dissection.
From January 1998 to March 2004, 29 patients (7 women and 22 men) with acute complicated aortic type B dissection (mean age, 61 years; range, 22-78), defined as aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with the Medtronic Talent device. Five patients (17%) had undergone previous surgery on the ascending aorta and/or aortic valve. The mean aortic diameter at intervention was 48 ± 13 mm. Follow-up was 100% complete and averaged 53 ± 41 months.
The technical feasibility and success with deployment proximal to the entry tear was 100%, requiring partial or total coverage of the left subclavian artery in only 1 patient (3%). Hospital mortality was 17% ± 7% (70% confidence limit) with 6 late deaths. The causes of hospital death included multiorgan failure in 2 patients, aortic rupture in 2, and retrograde dissection in 1 patient. Three patients (10%) who survived the procedure developed neurologic complications (2 strokes and 1 transient ischemic attack). One patient required early conversion to surgery because of retrograde type A dissection. Furthermore, 4 patients developed a type Ia endoleak. A postprocedural increase in the distal aortic diameter was observed in 3 patients. The actuarial survival at 1 and 5 years was 79% and 61%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complications, aortic-related death, or sudden, unexplained late death) was 82% and 77%, respectively.
Endovascular stent graft placement in acute complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, could further improve the prognosis of patients in this life-threatening situation.
评估血管内治疗急性复杂型 B 型夹层的疗效和中期结果。
1998 年 1 月至 2004 年 3 月，29 名患有急性复杂型 B 型主动脉夹层（平均年龄 61 岁，范围 22-78 岁）的患者（7 名女性和 22 名男性），夹层定义为主动脉破裂、灌注不良、难以控制的疼痛或高血压，接受了 Medtronic Talent 装置的血管内支架置入术。5 名患者（17%）既往接受过升主动脉和/或主动脉瓣手术。介入时平均主动脉直径为 48±13mm。随访率为 100%，平均为 53±41 个月。
近端至入口撕裂处的技术可行性和支架置入成功率为 100%，仅 1 名患者（3%）需要部分或完全覆盖左锁骨下动脉。住院死亡率为 17%±7%（置信区间 70%），6 例患者死于晚期。医院死亡的原因包括 2 例多器官衰竭、2 例主动脉破裂和 1 例逆行夹层。3 名（10%）幸存患者发生神经并发症（2 例脑卒中，1 例短暂性脑缺血发作）。1 名患者因逆行型 A 型夹层需要早期转为手术治疗。此外，4 名患者发生 I 型内漏。3 名患者术后出现远端主动脉直径增大。1 年和 5 年的存活率分别为 79%和 61%。1 年和 5 年无治疗失败率（包括再次干预、主动脉破裂、器械相关并发症、主动脉相关死亡或突发、原因不明的晚期死亡）分别为 82%和 77%。
在急性复杂型 B 型主动脉夹层中，血管内支架置入术是一种有前途的治疗方法，尤其是在这个治疗难度较大的患者群体中。支架设计和应用方面的改进可能会进一步改善这种危及生命情况下患者的预后。
